Provider Demographics
NPI:1124501895
Name:DEFRATES, KIMBERLY (DC)
Entity type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:
Last Name:DEFRATES
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 601
Mailing Address - Street 2:
Mailing Address - City:GWYNEDD VALLEY
Mailing Address - State:PA
Mailing Address - Zip Code:19437-0601
Mailing Address - Country:US
Mailing Address - Phone:215-855-5815
Mailing Address - Fax:215-855-5817
Practice Address - Street 1:412 PLYMOUTH RD
Practice Address - Street 2:601
Practice Address - City:GWYNEDD VALLEY
Practice Address - State:PA
Practice Address - Zip Code:19437
Practice Address - Country:US
Practice Address - Phone:215-855-5815
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-10
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC002696L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty